|
COBICISTAT 150 MG TABLET [207759]
|
Facility
|
OP
|
$11.33
|
|
|
Service Code
|
NDC 61958-1401-1
|
| Hospital Charge Code |
ERX207759
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.50
|
| Rate for Payer: Blue Shield of California Commercial |
$7.04
|
| Rate for Payer: Blue Shield of California EPN |
$6.65
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.63
|
| Rate for Payer: Dignity Health Senior |
$9.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$8.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.53
|
| Rate for Payer: TriValley Medical Group Senior |
$4.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.63
|
| Rate for Payer: Vantage Medical Group Senior |
$9.63
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
|
IP
|
$73.50
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$55.12 |
| Rate for Payer: Adventist Health Commercial |
$14.70
|
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.45
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.76
|
| Rate for Payer: Heritage Provider Network Senior |
$49.76
|
| Rate for Payer: Heritage Provider Network Senior |
$44.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.38
|
| Rate for Payer: Multiplan Commercial |
$49.61
|
| Rate for Payer: Multiplan Commercial |
$55.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.56
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
|
OP
|
$66.15
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$56.23 |
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Adventist Health Commercial |
$14.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$41.08
|
| Rate for Payer: Blue Shield of California Commercial |
$45.64
|
| Rate for Payer: Blue Shield of California EPN |
$38.83
|
| Rate for Payer: Blue Shield of California EPN |
$43.14
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.23
|
| Rate for Payer: Dignity Health Senior |
$56.23
|
| Rate for Payer: Dignity Health Senior |
$62.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.63
|
| Rate for Payer: Heritage Provider Network Senior |
$30.63
|
| Rate for Payer: Heritage Provider Network Senior |
$34.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$55.12
|
| Rate for Payer: Multiplan Commercial |
$49.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$26.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.40
|
| Rate for Payer: TriValley Medical Group Senior |
$29.40
|
| Rate for Payer: TriValley Medical Group Senior |
$26.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.48
|
| Rate for Payer: Vantage Medical Group Senior |
$56.23
|
| Rate for Payer: Vantage Medical Group Senior |
$62.48
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$3,447.32
|
|
|
Service Code
|
APR-DRG 7742
|
| Min. Negotiated Rate |
$3,447.32 |
| Max. Negotiated Rate |
$3,447.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,447.32
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$14,691.63
|
|
|
Service Code
|
APR-DRG 7744
|
| Min. Negotiated Rate |
$14,691.63 |
| Max. Negotiated Rate |
$14,691.63 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,691.63
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$6,272.82
|
|
|
Service Code
|
APR-DRG 7743
|
| Min. Negotiated Rate |
$6,272.82 |
| Max. Negotiated Rate |
$6,272.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,272.82
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$2,844.41
|
|
|
Service Code
|
APR-DRG 7741
|
| Min. Negotiated Rate |
$2,844.41 |
| Max. Negotiated Rate |
$2,844.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,844.41
|
|
|
Cochlear device implantation, with or without mastoidectomy
|
Facility
|
OP
|
$79,608.38
|
|
|
Service Code
|
CPT 69930
|
| Min. Negotiated Rate |
$351.95 |
| Max. Negotiated Rate |
$79,608.38 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62,848.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46,089.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41,899.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62,848.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$46,089.06
|
| Rate for Payer: Dignity Health Senior |
$41,899.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$41,899.15
|
| Rate for Payer: Humana Medicare |
$41,899.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$351.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41,899.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$79,608.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49,441.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52,792.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52,792.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$46,089.06
|
| Rate for Payer: TriValley Medical Group Senior |
$41,899.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62,848.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46,089.06
|
| Rate for Payer: Vantage Medical Group Senior |
$41,899.15
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 9999-3252-16
|
| Hospital Charge Code |
1716075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-00
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-00
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 9999-3252-16
|
| Hospital Charge Code |
1716075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-05
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-05
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CODEINE SULFATE 15 MG TABLET [1801]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 0054-0243-24
|
| Hospital Charge Code |
1730001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
CODEINE SULFATE 15 MG TABLET [1801]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 0054-0243-24
|
| Hospital Charge Code |
1730001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
OP
|
$1.03
|
|
|
Service Code
|
NDC 0054-0244-24
|
| Hospital Charge Code |
1730025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 0527-1698-01
|
| Hospital Charge Code |
1730025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
NDC 0054-0244-24
|
| Hospital Charge Code |
1730025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 0527-1698-01
|
| Hospital Charge Code |
1730025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
COENZYME Q10 100 MG CAPSULE [24678]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 7985407974
|
| Hospital Charge Code |
1711900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
COENZYME Q10 100 MG CAPSULE [24678]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 7985407974
|
| Hospital Charge Code |
1711900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
COENZYME Q10 100 MG CAPSULE [24678]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4098527413
|
| Hospital Charge Code |
1711900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
COENZYME Q10 100 MG CAPSULE [24678]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 8770140816
|
| Hospital Charge Code |
1711900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
COENZYME Q10 100 MG CAPSULE [24678]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4098527413
|
| Hospital Charge Code |
1711900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
